Patient Forms

 
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Request an Appointment
Call Us at 817-355-8000
Call Us at 817-355-8000
 

Patient Forms

  1. Patient Paperwork

Electronic Forms

  1. Parental Consent of Minor

  2. Disclosure and Consent of B-12 Injection Performed in Office

  3. Disclosure and Consent of Tuberculosis Test

  4. Disclosure and Consent of In-Office "Surgical" Procedures

  5. Patient Agreement for Controlled Substance

  6. Disclosure and Consent of Drug Screening

  7. Telemedicine Informed Consent Form

  8. X-Ray consent form

  9. Medical Record Release FROM MaxHealth

  10. Medical Record Release TO MaxHealth

  11. Financial Disclosure And Agreement

  12. IUD Insertion Consent 

  13. HIPAA and Notice of Privacy Acknowledgement 

  14. ABC Symptom Survey

  15. Motor Vehicle Accident & Third-Party Liability Waiver Form

  16. Injury Waiver Form

  17. MaxHealth Office Policies

Printable Patient Forms

  1. Medical Record Release FROM MaxHealth

  2. Medical Record Release TO MaxHealth

  3. Symptom Survey Form

  4. Injury Waiver Form

  5. Motor Vehicle Accident & Third-Party Liability Waiver Form

  6. Guidance For Care & Isolation After Testing

  7. COVID Symptom Tracker

  8. ImmTrac2 Minor Consent Form

  9. ImmTrac2 Adult Consent Form

  10. ImmTrac2 Withdrawal of Consent and Confirmation Form

  11. Notice of Privacy Practices